Every finding on record at Prudential Home Health Corporation

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/28/26. Standard level deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on Emergency Preparedness Plan binder review and staff interview, the Agency failed to ensure that the Agency conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Emergency Preparedness Plan as required. Findings include: 1. The Agency’s Emergency Preparedness Plan binder was reviewed on 01/26/26. The Emergency Preparedness Plan binder included Fire drill testing exercises for the year 2023, 2024 and 2025. The Plan lacked documentation that the Agency activated the Emergency Preparedness Plan for an actual emergency or participated in a full scale/community-based testing exercise, as required. 2. During an interview with the Administrator on 01/28/26 at 2:40 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements and complaints #104981/242257 and 104787/242236 on 01/28/26. Standard level deficiencies cited. Abbreviations: POC / PsOC = Plan of Care / Plans of Care PT = Physical Therapy OT = Occupational Therapy SN = Skilled Nurse Pt / Pts = Patient / Patients. lbs = pounds

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 12 of 98 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 01/26/25 to 01/26/26, was reviewed on 01/26/26. The report documented 12 of 98 (12.24%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator, Agency Supervisor and Quality Assurance / Office staff on 01/27/26 at 1:30 PM, the Administrator confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, in 4 of 7 (Pts# 1,3,2 and 5) clinical records, the Agency failed to provide services included in the POC. Findings include: 3. Pt. #2 was admitted to Home Health services on 01/03/26 with diagnosis of Cerebral Infarction. The clinical record was reviewed on 01/26/26. The record included a POC for certification period 01/03/26 to 03/03/26. The POC included an order written on 01/03/26 for Physical Therapy (PT) evaluation. The clinical record lacked evidence of PT evaluation. 4. Pt. # 5 was admitted to Home Health services on 12/13/25 with diagnosis of Other specified peripheral vascular diseases. The clinical record was reviewed on 01/26/26. The clinical record included a POC for certification period 12/13/25 to 02/10/26 that required PT frequency of 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 4 weeks. The clinical record lacked PT visits weeks of 12/14/25 and 12/21/25 (weeks 2 and 3) of certification period. 5. Findings of Agency staff not providing services ordered in the PsOC were confirmed during interviews with the Administrator, Nursing Supervisor and Quality Assurance on 01/27/25 between 1:30PM and 3:00PM. 2. Pt. #3 was admitted to Home Health Services on 09/29/2025 with the diagnosis of Heart Failure. The clinical record was reviewed on 01/26/2026. The clinical record included a POC dated 12/10/2025 that included an order for Physical Therapy and Occupational Therapy to evaluate and treat. The record inlcuded a Physical Therapy Evaluation dated 12/17/2025 that ordered PT visits one time a week for six weeks. The clinical record lacked documentation PT visits were conducted the weeks of 12/29/2025 and 01/05/2026. The record also included an Occupational Therapy Evaluation dated 12/16/2025 ordering OT one time a week for six weeks. The record lacked documentation of OT visits for the weeks of 01/12/2026 and 01/19/2026. The PT and OT frequency were not followed as ordered. There were no modification orders to the visit frequencies for PT and OT in the clinical record. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included PsOC for the certification period of 11/11/25 to 01/09/25 that required: “….The skilled nurse will perform weekly weight monitoring and notify the physician for weight gain of 3 lbs in one day and/or 5 lbs in one week…” and a resumption POC for certification period of 01/10/26 to 03/10/26, that required: “….report weight gain of three pounds in a day or five pounds in a week….” The Skilled Nurse visit note dated 01/19/26, lack a weight assessment as ordered. During a home visit conducted with Employee # 4 (Registered Nurse / Date of hire 06/15/15) on 01/26/26 at 1:30 PM, there was no weight assessment, as ordered.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records reviewed, home visit observation and interviews, for 2 of 7 (Pts. # 3 and 7) clinical records reviewed the Agency failed to ensure the plans of care included all pertinent interventions and medications. Findings include: . 1.The clinical record for Pt. #3 was reviewed on 01/26/26. Pt. #3 was admitted to home health on 09/29/2025 with a diagnosis of heart failure. The clinical record included a POC dated 11/28/25 that ordered SN visitis one time a week for nine weeks. The nursing notes dated 12/01/25, 12/15/25, 12/29/25 and 01/05/26 included documentation the nurse assessed the patients IV access/Med-A-Port. The plan of care lacked documented interventions for the Med-A-Port. The record included a Resumption of Care SN note dated 12/22/25. The SN note documented medication reconciled. The note inlcuded an attachment of a hospital discharge dated 12/21/25. The discharge document included a medication list that included..."aspirin 81 mg... atorvastatin 40 mg... clopidogrel 75 mg... ferrous sulfate 325 mg... furosemide 40 mg... letrozole 2.5 mg..." The Resumption of care visit narrative documented "...updated plan of care..." The POC completed on 12/22/25 lacked the above mentioned medications. A home visit was conducted on 01/27/26 at 11:15 AM with Pt. #3. During the home visit the patient confirmed the medication on the hospital medication list were her current medications. 2. The clinical record for Pt. #7 was reviewed on 01/26/26. Pt. #7 was admitted to home health services on 01/25/25 with the diagnoses of hypertension and lower back pain. The POC dated 01/25/25 through 03/25/25 ordered SN visits one time a week for one week, two times a week for two weeks and 1 time a week for six weeks. The SN visit notes dated 01/31, 02/01, 02/05, 02/08, and 02/12 all documented the patient had pain and used medication to reduce pain. The plan of care lacked documentation of medication the patient used for pain. 3. During an interview with the Administrator, the Director of Nuring and the Quality Assurance/Office Staff on 01/27/2026 at 2:15 PM, the above findings were confirmed. The plans of care lacked a complete list of medications and interventions.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observation, Agency policy review and staff interview, for 1 of 3 (Pt. #1) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. During a home visit conducted with Employee # 4 (Registered Nurse / Date of hire 06/15/15) on 01/26/26 at 1:30 PM, Employee # 4 was observed to put down nursing bag on the floor next to the kitchen table in Pt. #1’s home without placing a barrier. During an interview with Employee # 4 on 01/26/26 at 2:00 PM, Employee # 4 confirmed that there was no barrier between nursing bag and the floor. 2. The Agency policy titled:” Bag Technique” was reviewed on 01/27/26 and required: “…. Procedure: 1. Spread the poly towel provided on the surface before setting the bag down….” 3. During an interview with the Administrator, Director of Nursing and Quality Assurance/Office Staff on 01/27/26 at 2:40 PM, the Administrator confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interviews, in 3 of 7 (Pts. # 1, 3 and 6) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. 3. Pt # 6 was admitted to Home Health services on 09/29/25 with diagnosis of Chronic combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included a document titled "Advance Beneficary Notice of Non-coverage" signed by the patient on 09/29/25. The document was incomplete, lacked information on what service / items Medicare may not pay. 4. Finding of Agency having incomplete documentation in the clinical records was confirmed during interviews with the Administrator, Director of Nursing and Quality Assurance / Office Staff on 01/27/26 between 1:30 PM and 3:15 PM. 2. Pt. #3 was admitted to home health services on 09/29/2025 with the diagnosis of heart failure. The clinical record was reviewed on 01/26/2026. The clinical record included a form titled: “Vaccination Form”, dated and signed by Pt. #3 and nurse, and included sections for history of vaccination Patient’s response, Referral for Vaccination and Follow up remarks. These sections were incomplete. The clinical record also included the form titled: “Advance Beneficiary Notice of Non-coverage (ABN), signed by Pt. #3 and dated 09/29/2025, the form was incomplete. The section of the form that would include what was not covered was left blank. The clinical record included nursing notes dated 12/01/2025, 12/15/205, 12/29/2025 and 01/09/2026. The nursing notes documented a "Med-A-Port" to the upper right chest with a dressing that was dry and intact. The notes also included documentation the area was open to air. During an interview with the Administrator, Director of Nursing and QA/Office staff on 01/27/2026 at 2:15 PM, it was confirmed the documentation was inaccurate. The IV access could not have a dressing and be open to air at the same time. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included a form titled: “Vaccination Form”, dated and signed by Pt. #1 and nurse, and included sections for history of vaccination, Patient’s response, Referral for Vaccination and Follow up remarks. These sections that were required to be filled up, were left blank/incomplete. The clinical record also included the form titled: “Advance Beneficiary Notice of Non-coverage (ABN), signed by Pt. #1 and dated 11/11/25, lacked complete information on what is not covered, as the form required.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Action Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan was based on a risk assessment and updated. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. On 10/25/22 at 12:50 PM, the “Emergency Preparedness Action Plan” was reviewed on 8/23/21 at 11:45 AM. The Plan contained multiple forms titled, "Hazard Vulnerability Assessment" which were left blank. As of 10/25/22, the Agency lacked documentation its Emergency Plan was developed from a facility and community-based, all-hazards approach risk assessment. 2. During an interview with the Administrator and Director of Nursing on 10/26/22 at 3:15 PM, the Administrator confirmed the Emergency Preparedness Action Plan lacked an all-hazards facility and community-based risk assessment.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Action Plan and staff interview, it was determined the Agency failed to ensure the Communication Plan was complete. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. On 10/25/22 at 12:50 PM, the “Emergency Preparedness Action Plan” was reviewed which contained a Communication Plan and included the "Emergency Phone Tree". As of 10/25/22, the "Emergency Phone Tree" lacked the names and contact information of contracted staff/agencies and patient's physicians. 2. During an interview with the Administrator and Director of Nursing on 10/26/22 at 3:15 PM, the Administrator confirmed the Emergency Preparedness Action Plan was incomplete.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Action Plan and staff interview, it was determined the Agency failed to conduct staff training biennially, relative to the Agency's Emergency Preparedness Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Action Plan was reviewed on 10/25/22 at 12:50 PM. The Plan lacked documentation the Agency provided staff training in 2020, 2021 and 2022 pertaining to the Agency's Emergency Preparedness Action Plan. 2. During an interview with the Administrator and Director of Nursing on 10/26/22 at 3:15 PM, the Administrator stated staff last received training in 2019. During the same interview, the Administrator confirmed the Agency failed to provide staff training in 2020, 2021 and 2022 pertaining to the Agency's Emergency Preparedness Action Plan.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Action Plan and staff interview, it was determined the Agency failed to document the activation of its Emergency Preparedness Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. On 10/25/22 at 12:50 PM, the "Emergency Preparedness Action Plan" was reviewed. The Plan contained documentation that staff were educated on COVID-19, a public health emergency in March 2020. The Plan lacked documentation of who activated the Agency's Emergency Preparedness Action Plan, when and how the Plan was activated. 2. During an interview with the Administrator and Director of Nursing on 10/26/22 at 3:15 PM, the Administrator stated the Agency's Emergency Preparedness Action Plan was activated in March 2020 due to COVID-19. During the same interview with the Administrator, it was confirmed that the Agency failed to document activation of the Emergency Preparedness Action Plan in 2020.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: AM = morning PM = evening # = number WK = week POC = Plan of Care SOC = Start of Care Pt./Pts. = patient/patients SN = Skilled Nurse OT = Occupational Therapy/Therapist OTA = Occupational Therapy Assistant PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant COVID-19 = Corona Virus Disease 2019

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation during home visits and staff interview, it was determined the Agency failed to ensure Pts. were informed and/or participated in the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 10/26/22 from 10:30 AM to 3:30 PM: Pt. #1. SOC: 8/4/22. Pt. received SN and PT services. Pt. #2. SOC: 5/19/22. Pt. received SN and PT services. Pt. #3. SOC: 6/2/22. Pt. received SN, PT and OT services. Pt. #4. SOC: 8/3/22. Pt. received SN and PT services. Pt. #5. SOC: 8/18/22. Pt. received SN, OT and Home Health Aide services. Pt. #6 SOC: 2/26/22. Pt. received SN and PT services. Pt. #7 SOC: 6/7/22. Pt. received SN and OT services. The records lacked documentation that during the SOC, the Pt./patient's representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. On 10/25/22 at 2:30 PM and 10/26/22 at 12:00 PM, the following home visits were conducted: Pt. #1. SOC: 8/4/22. Pt. #2. SOC: 5/19/22. Pt. #3. SOC: 6/2/22. During the home visits, the patient's admission folder was observed and lacked documentation of each discipline's frequency of visits. 3. During an interview with the Administrator and Director of Nursing on 10/26/22 from 3:30 PM to 4:15 PM, the Administrator confirmed the above findings.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. are advised of the extent of their financial liability for care, and/or services before care is initiated. This was found in 7 of 7 (Pts. #1 to 7) clinical records reviewed. Findings include: 1. The clinical records of the Pts. listed below were reviewed on 10/26/22 from 10:30 AM to 3:30 PM. The records contained a form titled: “Information” with the section titled: “Authorization of Benefits.” The section/the record lacked documentation indicating the patient's financial responsibility. Pt. #1 SOC: 8/4/22 Pt. #2 SOC: 5/19/22 Pt. #3 SOC: 6/2/22 Pt. #4 SOC: 8/3/22 Pt. #5 SOC: 8/18/22 Pt. #6 SOC: 2/26/22 Pt. #7 SOC: 6/7/22 2. The above findings were confirmed during an interview with the Administrator and Director of Nursing on 10/26/22 from 3:15 PM to 4:15 PM.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: A. Based on review of the Agency's Pt. admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. 1. The Agency's admission folder was reviewed on 10/25/22 at 10:15 AM and lacked documentation of the Agency's transfer and discharge policies. 2. The clinical records of the following Pts. were reviewed from 10/26/22 from 10:30 AM to 3:30 PM: Pt. #1. SOC 8/4/22. Pt. #2. SOC 5/19/22. Pt. #3. SOC 6/2/22. Pt. #4. SOC 8/3/22. Pt. #5. SOC 8/18/22. Pt. #6. SOC 2/26/22. Pt. #7. SOC 6/7/22. The records lacked documentation the Agency provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 3. The following home visits were conducted on 10/25/22 at 2:30 PM and 10/26/22 at 12:00 PM: Pt. #1. SOC 8/4/22. Pt. #2. SOC 5/9/22. Pt. #3. SOC 6/2/22. During the home visits, the Pt. admission folders were observed, and lacked documentation of the Agency's transfer and discharge policies. 4. During an interview with the Administrator and Director of Nursing on 10/27/22 at 9:30 AM, the Administrator confirmed the Agency failed to provide their Pts. information regarding the Agency's transfer and discharge policies.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff conducted Pt. immunization screening at the SOC, as required by the Agency. This was found in 7 of 7 (Pts. #2, 3, 4, 1, 5, 6 and 7) clinical records reviewed. 4. Pt. #1. SOC 8/4/22. Principal Diagnosis: Overweight. The clinical record was reviewed on 10/26/22 at 10:30 AM. The record contained the SOC comprehensive assessment completed by the SN on 8/4/22. The record lacked information on influenza and pneumonia status of Pt. #1, as required by the Agency. 5. Pt. #5. SOC 8/18/22. Principal Diagnosis: Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 10/26/22 at 11:30 AM. The record contained the SOC comprehensive assessment completed by the SN on 8/18/22. The record lacked information on influenza and pneumonia status of Pt. #5, as required by the Agency. 6. Pt. #6. SOC 2/26/22. Principal Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 10/26/22 at 1:30 PM. The record contained the SOC comprehensive assessment completed by the SN on 2/26/22. The record lacked information on influenza and pneumonia status of Pt. #6, as required by the Agency. 7. Pt. #7. SOC 6/7/22. Principal Diagnosis: Primary General Osteoarthritis. The clinical record was reviewed on 10/26/22 at 3:30 PM. The record contained a SOC comprehensive assessment completed by the SN on 6/7/22. The record lacked information on influenza and pneumonia status of Pt. #7, as required by the Agency. 8. The Agency Policy “Influenza Vaccination” which was reviewed on 10/25/22 at 12:30 PM, required: "Agency) will annually administer or arrange for administration of a vaccination against influenza to each client/Pt. in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, unless the vaccination is medically contraindicated, or the Pt. has refused the vaccine… 6.The nurse shall document in the client’s/patient’s medical record that an annual vaccination against influenza was administered, arranged, refused, or medically contraindicated or the client/Pt. is not a member of a vaccination priority population. 7. The Agency shall carry out documentation and keep records which will reflect a) Individual Pt. record entries identifying the assessment for the need of vaccination; date of referral; client/Pt. response; administration, contraindication, or refusal and any follow-up activities. b) standard check-off form recording Pt. specific information, including the assessment for the need off vaccination, date of offer, or referral, Pt. response, administration, contraindication or refusal and any follow-up activities.” 9. The Agency Policy “Pneumococcal Pneumonia Vaccination” which was reviewed on 10/25/22 at 1:00 PM required: “(Agency) will annually administer or arrange for administration of pneumococcal vaccination, in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention to Pts. who is age 65 or over and who has not received this immunization prior to or upon service initiation, unless the Pt. refuses the offer for vaccination or the vaccination is medically contraindicated… 3. (Agency) shall document in each client’s/patient’s medical record that a vaccination against pneumococcal pneumonia was offered and administered, arranged, refused, or medically contraindicated or that the client/Pt is not a member of a vaccination priority population. 4. (Agency) shall record and keep, a) Individual client/Pt. record entries identifying the assessment for the need of vaccination; date of offer or referral; client/Pt response; administration, contraindication, or refusal; and any follow up activities. b) standard check-off form recording Pt. specific information, including the assessment for the need off vaccination, date of offer, or referral, Pt. response, administration, contraindication or refusal and any follow-up activities.” 10. During the entrance interview with the Administrator and Director of Nursing on 10/25/22 at 10:30 AM, it was stated the assessment of Influenza and Pneumonia vaccination status is conducted during admission and recorded in the patient’s SOC comprehensive assessment document. During an interview with the Administrator and Director of Nursing on 10/26/22 from 3:15 PM to 4:15 PM, the above findings were confirmed. Findings include: 1. Pt. #2. SOC 5/19/22. Primary Diagnosis: Unspecified Hyperlipidemia. The clinical record was reviewed on 10/26/22 at 1:30 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 5/19/22. The form and/or the record lacked documentation the SN assessed the patient's need for the Influenza and Pneumococcal Pneumonia vaccines, as required by the Agency. 2. Pt. #3. SOC 6/2/22. Primary Diagnosis: Atherosclerotic Heart Disease with Native Coronary Artery with Unspecified Angina Pectoris. The clinical record was reviewed on 10/26/22 at 10:40 AM. The record contained the SOC comprehensive assessment completed by the SN and dated 6/2/22. The form and/or the record lacked documentation the SN assessed the patient's need for the Influenza and Pneumococcal Pneumonia vaccines, as required by the Agency. 3. Pt. #4. SOC 8/3/22. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 10/26/22 at 2:15 PM. The record contained the SOC comprehensive assessment completed by the SN and dated 8/3//22. The form and/or the record lacked documentation the SN assessed the patient's need for the Influenza and Pneumococcal Pneumonia vaccines, as required by the Agency.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service, as indicated on the POC and/or required\ by the Physician. This was found in 2 of 2 (Pts. #3 and 7) clinical records reviewed, wherein OT services were provided. 2. Pt. #7. SOC: 6/7/22. Principal Diagnosis: Primary General Osteoarthritis. The clinical record was reviewed on 10/26/22 at 3:00 PM. The record included a POC for the certification period of 8/6/22 to 10/4/22 which required OT Frequency: "to assess, evaluate and treat"; a physician order dated 8/15/2 and an OT Care Plan which required: "Occupational Therapist to evaluate and treat: 1 WK 6..." The record lacked documentation of OT visits for the weeks of 8/21/22 to 8/27/22, 9/11/22 to 9/17/22 and 9/18/22 to 9/29/22 and lacked documentation of why these OT visits were missed. 3. During an interview with the Administrator and Director of Nursing on 10/26/22 from 3:15 PM to 4:15 PM, the above findings were confirmed. Findings include: 1. Pt. #3. SOC 6/2/22. Primary Diagnosis: Atherosclerotic Heart Disease with Native Coronary Artery with Unspecified Angina Pectoris. The clinical record was reviewed on 10/26/22 at 10:40 AM. The record contained the OT evaluation form and care plan dated 7/25/22 signed by the Physician, and included the visit frequency of "2WK4, 1WK4 starting 08/01/22". As of 10/26/22, the record lacked documentation the OT provided any service during the weeks of 7/31/22 to 8/6/22 and 8/7/22 to 8/13/22.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the OT supervised the OTA as required. This was found in 1 of 2 (Pt. #3) clinical records reviewed, wherein OTA services were provided. Findings include: 1. Pt. #3. SOC 6/2/22. Primary Diagnosis: Atherosclerotic Heart Disease with Native Coronary Artery with Unspecified Angina Pectoris. The clinical record was reviewed on 10/26/22 at 10:40 AM. The record contained the OT evaluation form and care plan dated 7/25/22, then OTA visit notes dated 8/19/22, 8/22/22, 8/24/22, 8/29/22, 8/31/22 and 9/9/212. The OT conducted a reassessment on 9/11/22, the OTA provided service on 9/12/22, 9/21/22, and the OT discharged the Pt. on 9/26/22. The record lacked documentation the OT supervised the OTA from 8/17/22 to 9/26/22. 2. The Agency policy titled; "Occupational Therapist Assistant Supervision Policy" was reviewed on 10/27/22 at 10:30 AM. The policy included: "...Occupational therapy assistant supervision will be done on the 6th (sixth) visit of the episode. Supervision must be documented... no more than 5 (five) days after the visit." 3. During an interview with the Administrator and Director of Nursing on 10/26/22 at 3:30 PM, the Administrator confirmed the OT failed to supervise the OTA.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 5 of 7 (Pts. #5, 7, 2, 3 and 4) clinical record reviewed. 3. Pt. #2. SOC 5/19/22. Primary Diagnosis: Unspecified Hyperlipidemia. The clinical record was reviewed on 10/26/22 at 1:30 PM. The record contained the form titled, "Information" signed by the Pt. and dated 5/19/22 which included, the consent for treatment and other information. The Agency's form required the SN to sign their name above the line titled, "Signature of Witness/Visiting Nurse" and enter the date that the Witness signed the form, this section was left blank. The untitled form signed by the Pt., SN and dated 5/19/22, required the SN to place a check mark indicating whether the Pt. had or had not executed an advance directive (Living Will, Durable Power of Attorney Health Care and/or Designation of Health Care Surrogate). The form was left blank, it lacked a check mark indicating whether the Pt. had an advance directive. The form titled, "Authorization for Release of Patient Health Information" was signed by the Pt., completed by the SN and dated 5/19/22. The form lacked documentation of the person's name or institution the protected health information to be forwarded, purpose or need for the information, to and from dates indicating the time frame of the clinical record to be sent. 4. Pt. # 3. SOC 6/2/22. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris. The clinical record was reviewed on 10/26/22 at 10:40 AM. The record contained an untitled form signed by the Pt., SN and dated 6/2/22 requiring the SN to place a check mark, indicating whether the Pt. had or had not executed an advance directive. The form was left blank, it lacked a check mark indicating whether the Pt. had an advance directive. The form titled, "Authorization for Release of Patient Health Information" was signed by the Pt., completed by the SN and dated 6/2/22. The form lacked documentation of the person's name or institution the protected health information to be forwarded, purpose or need for the information, to and from dates indicating the time frame of the clinical record to be sent. The form titled, "Request for Home Health Services Termination" was signed by the Pt, SN and dated 6/2/22. The form required the SN to document the name of the Agency that the Pt. previously received service or had transferred from, this section was left blank. 5. Pt. #4. SOC 8/3/22. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 10/26/22 at 2:15 PM. The record contained the form titled, "Information" signed by the Pt. and dated 8/3/22. The form lacked the SN signature that completed the form and the date that the SN signed the form. The untitled form signed by the Pt. and dated 8/3/22 that required the SN to place a check mark, indicating whether the Pt. had or had not executed an advance directive. The form was left blank, it lacked a check mark indicating whether the Pt. had an advance directive, and lacked the SN signature and date the SN reviewed the form with the Pt. The record contained 2 identical forms titled, "Authorization for Release of Patient Health Information", signed by the Pt., and dated 8/3/22. The forms lacked documentation of the person's name or institution the protected health information to be forwarded, purpose or need for the information, to and from dates indicating the time frame of the clinical record to be sent, and the SN signature/name that initiated these forms. 6. During an interview with the Administrator and Director of Nursing on 10/26/22 from 3:30 PM to 4:15 PM, the Administrator confirmed the forms were incomplete and/or inaccurate. Findings include: 1. Pt. #5. SOC 8/18/22. Principal Diagnosis: Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 10/26/22 at 11:30 AM. The record contained a form, "Request for Home Health Services Termination.” The form was signed and dated by the Pt. but lacked the name of the agency from which the Pt. is being transferred from and the effective date. During an interview conducted with the Administrator on 10/26/22 at 4:10 PM, it was stated that the form “Request for Home Health Services Termination” for Pt. #5 should not be filled not because Pt. was not transferred from another Home Health Agency. 2. Pt. #7. SOC 6/7/22. Principal Diagnosis: Primary General Osteoarthritis. The clinical record was reviewed on 10/26/22 at 3:00 PM. The record contained a form, "Request for Home Health Services Termination.” The form was signed and dated by the Pt. but lacked the name of the agency from which the Pt. is being transferred from. The record also contained an untitled form regarding patient’s Advance Directives, which was signed and dated by the Pt. but was not filled out and lacked a mark indicating whether the Pt. had an advance directive. During an interview conducted with the Administrator on 10/26/22 at 4:10 PM, it was stated that the form “Request for Home Health Services Termination” for Pt. #7 should not be filled not because Pt. was not transferred from another Home Health Agency.